Philosophy – Strategy – Tactics – Techniques

Transformational Collaborative Outcomes Management (TCOM)

• the measurement and management of information regarding the characteristics of children and families is the single most important focus of managing treatment interventions at all levels of the system of care simultaneously

Redressing the Emperor: Improving Our Children’s Public Mental Health System (Lyons, 2004) 2

Transformational Collaborative Outcomes Management (TCOM)

• Philosophy—always return to the shared vision. In the child serving system the shared vision are the need and strengths of children and families we serve.

• Strategy—represent the shared vision and communicate it throughout the system with a standard language/assessment

• Tactics—activities that promote the philosophy at all the levels of the system simultaneously

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The Philosophy: Transformational Collaborative Outcomes Management (TCOM)

• Transformation means that it is focused on the personal change that is the reason for intervention.

• Collaborative means that a shared visioning approach is used--not one person’s perspective.

• Outcomes means the measures are relevant to decisions about approach or proposed impact of interventions.

• Management means that this information is used in all aspects of managing the system from individual family planning to supervision to program and system operations.

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The Strategy: The Child and Adolescent Needs and Strengths

• Shared Vision approach• About the child not the child-in-care• Consider culture and development before establishing the action levels• About the ‘what’ not the ‘why’

• Information Science approach (relevant, actionable and timely)• Each item is relevant for decision support for children and families• Levels of the items translate immediately into action• Is it relevant in the last 30 days?

Individual Program System

Decision SupportCare Planning

Effective practicesEBP’s

EligibilityStep-down

Resource ManagementRight-sizing

Outcome Monitoring

Service Transitions & Celebrations Evaluation

Provider ProfilesPerformance/ Contracting

Quality Improvement

Case ManagementIntegrated Care

Supervision

CQI/QAAccreditation

Program Redesign

TransformationBusiness Model Design

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The Tactics: TCOM Grid of Tactics

Transformational Collaborative Outcomes Management (TCOM)

• Philosophy—always return to the shared vision. In the child serving system the shared vision are the need and strengths of children and families we serve.

• Strategy—represent the shared vision and communicate it throughout the system with a standard language/assessment

• Tactics—activities that promote the philosophy at all the levels of the system simultaneously

• Techniques – skills that promote the integration of the strategy into practice settings

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The Techniques: Approaches to integrating the strategy into your everyday work

• Assess• Communicate how we may work differently using a TCOM framework• Engage Family, Youth, Team Stakeholders• Collect information• Build consensus

• Plan • Identify relative nature of needs and strengths• Organize strengths and needs for planning (Treatment Targets, Background Needs,

Anticipated Outcomes)• Set goals/objectives, define action steps

• Intervene• Monitor progress towards goals and objectives

Organize our work with the tool around our practice.

Once we can clearly identify our practice, we can identity successful strategies for integration.

CANS as an Integrative Measure

Decision Points in our Work

Grid of Decision Points (Tactics / Techniques)

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Access Engagement Service Appropriateness

Service Effectiveness

Linkages

Screening Collaborative assessment

Collaborative Service / Treatment Planning

Re-assessment / Outcomes Management

TransitionPlanning

CollaborativeInformation Gathering

Data Driven Process

Engagement

Building the collaborative (effective teams)

Effective info sharing;

Building consensus

Organization of the needs and strengths

Theory of change (clinical formulation)

Goal development (measurable and achievable)

Building strengths

Collaborative Plan Review

Quality Service ReviewProcesses

Referral / outcome management

Service adjustments

Enhancing community linkages

Defining success

Using outcome data to enhance expertise

Question:

How does your agency teach/develop expertise in the essential skills for front line and supervisory staff?

Approaches for Building Mastery• Addressing implementation fatigue – When beginning on a new approach, or

implementing a new strategy, it is helpful if the strategy can be understood in relationship to other tasks, strategies that have preceded it.

• Is this strategy consistent with other initiatives? • Does it replace them or complement them? • Where can bridges be built? • How does this fit into the big picture?

• Define Vital Skills

• Practice / Plan for all interactions

• Gather feedback, use that to improve mastery

Our Assumptions

• We have high expectations for the quality of our interactions/services/interventions

• We believe that we can be successful with all of our children and families.

• Everyone must participate in the learning experience and mastery has to be demonstrated

• Build comfort with technical vocabulary

• Develop a sense of pride for mastering collaborative assessment and planning

How do we “Define Vital Skills”?

What are the essential elements of our work that lead to positive outcomes?

What are the current barriers to achieving change? What skills can address those barriers?

What parts of the assessment planning process do you find the most frustrating?

Skills and Drivers

Developing Fluency

• There are too many items!

• The items don’t reflect my work with this youth and family.

Team Building, Collaboration and Consensus

• I complete the CANS on my own.

• I can’t use the CANS in a team meeting.

• I don’t use the CANS to make decisions.

Skills and Drivers

Collaborative Planning using the CANS

• The CANS is not reflected in my plan.

• I can’t use the CANS for planning with my family.

Outcomes/Referal Management

• I can’t use the CANS to measure change with my youth and family.

• I can’t do another CANS.

Learning the Language of the CANS

• We recognize the value of the CANS as a communication tool

• But how do we develop proficiency in learning to how to communicate and interpret the language of the CANS?

Language Acquisition

• Stages of Second Language Acquisition• Pre-Production

• Developing the vocabulary/learning the words• Early Production

• Putting those words together to form short chunks• Speech Emergence

• Use of simple phases and sentences• Intermediate Fluency

• Use of more complex sentences to articulate thoughts and express opinions• Advanced Fluency

• Cognitive fluency/Nearing native proficiency

Stage Characteristics

Preproduction • Certification training• Reading the manual

Early Production • Completion if the tool involves referencing the manual for each rating

Speech Emergence• Has good comprehension of the tool. • Occasionally uses the manual to understand items.• Occasionally misses connection between multiple items.

Intermediate Fluency • Has excellent comprehension.• Use of the tool is quick and efficient.

Advanced Fluency• The student has a near-native level of speech.• Frequently makes CANS jokes around the office.• Begins developing their own version of the tool.

Language Development (cont.)

• Language is best learned through immersion

• Enhancing expertise in communicating the language of the CANS (Item Definitions/Ratings)

• Facilitates efficient work• Don’t need to constantly reference the manual or anchor

definitions• Completing the assessment becomes a more natural process of

“plugging in” the needs and strengths

Language Development (cont.)• Strategies

• CANS Bingo!• Flash Cards• Case Consultation Exercises

• Reviewing completed CANS assessments while the worker discusses the case

• Scoring the assessment as a group• Prioritizing mastery of sections of the assessment• Providing guidelines for interview questions

Building Effective Teams

What Makes an Effective Team?

Question?

• What do you teach staff about building teams that achieve outcomes?

What does research tell us?*

• Sense of safety• Group norms

*”What Google Learned From Its Quest to Build the Perfect Team”http://www.nytimes.com/2016/02/28/magazine/what-google-learned-from-its-quest-to-build-the-perfect-team.html?_r=0

Skilled Facilitation

• A Clearly Defined Facilitator Role

• Explicit Core Values

• Ground Rules

• The Diagnosis-Intervention Cycle

• Openness to Exploring and Changing How We Think

• A Process for Agreeing on How to Work Together

Ground Rules for Effective Groups• Test assumptions• Share all relevant information.• Use specific examples, and agree on what important words

mean.• Combine advocacy and inquiry.• Jointly design steps and ways to test disagreements.• Discuss undiscussable issues.• Use a decision-making rule that generates the level of

consensus.

Teaching Teambuilding

• Let’s collaborate and learn from each other

• Build on the strengths and expertise of our program in order to:• Identify Challenges• Develop Strategies• Explore Resources

Teaching Teambuilding• Organized activities

• Wilderness Survival: A Consensus-Seeking Task

• Prisoners’ Dilemma: An Intergroup Competition

• Lost at Sea: A Consensus-Seeking Task

Building Skills for Collaboration

Collaboration Skills

• Just because we have a collaborative assessment doesn’t necessarily mean that we are being collaborative.

• What does true collaboration really look like?

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The Complexity of Our System

Different Goals and Perspectives?

YouthBio Family

Foster Parent

Out-Patient Therapist

School Social

Worker

DSS Worker

TFC Worker

Attorney

CASA Worker

Psychiatrist

Strategies for Collaboration

• Developing a script• How do you introduce the assessment?

• Training for caregivers

• Role playing with staff

• Use of video/modeling

• For larger teams, start with the family

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Collaboration and Consensus Building

• Collaboration is about alignment of the shared vision and working collectively to achieve a common goal

• Consensus is about building agreement on what needs to happen in order to achieve the common goal.

Consensus Oriented Decision Making Model:

• Framing the problem.

• Having an open discussion.

• Identifying underlying concerns.

• Developing proposals.

• Choosing a direction.

• Developing a preferred solution.

Hartnett's Consensus-Oriented Decision-Making (CODM) model. (2011)40

“Consensus means general agreement, not total agreement. Although this

model allows everyone to participate in developing solutions, not everyone will always agree with the final decision.”

Hartnett's Consensus-Oriented Decision-Making (CODM) model. (2011)41

Teaching Consensus building• Use the Organized

Teambuilding Activities

• Use real issues within the agency. Places where people are “stuck” brainstorm strategies for getting “unstuck”

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Collaborative Strategies for the Development of a

Plan

A SIMPLE VERSION OF THE PROCESS OF CARE

• START with the ‘WHAT’ (describe the circumstance)

• CONSIDER the ‘WHY’ (understand what is happening. This is a clinical formulation)

• DETERMINE the ‘HOW’ (develop a plan to help)

Theory of Change/Clinical Formulation

Where are you now?What are our treatment

targets?How are we going to get

there?Defining our interventions

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Where do we want to be?What is our desired

outcome?

Step 1:Identifying Needs and Strengths

Complete the CANS

Step 1a:Organize Needs and Strengths

Organizing the Assessment

• Two factors will necessitate the creation of clusters when summarizing the assessment:

• Single needs will show up in multiple places on the assessment. (These should be organized into a cause and effect framework.)

• Needs and Strengths that can be addressed by a single intervention.

Step 2: Developing the Goal

•What will change look like for this youth/family?

Step 3: Define Objectives and Action Steps

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• How are we going to get there?• What interventions will be

effective in addressing identified needs?

• How do we operationalize strengths and use them?

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Case Example “Barack”• Barack is a 17 year old, who is preparing to graduate from High

School in the next few months. He has been living with his current foster family, Mr. and Mrs. Johnson, for the past 8 years. Barack’s social worker is scheduled to update his CANS assessment and quarterly action plan, as he will be transitioning to an independent living program around the same time.

• His social worker is scheduling a team meeting and inviting several adults from Barack’s life (teachers, coaches, grandparents and family friends), to participate in the meeting. Barack has recently been expressing a lot of worry about losing the support of his foster family, as well as the other supports that he is currently accessing.

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Case Example “Barack” (cont.)• Barack is a very social and active young man. He is always seeking out

opportunities for participating in extracurricular activities and student organizations. His teachers and school counselors have described him as a leader amongst his peers and somebody who will stand up and defend other students when they are being bullied or teased. He is well liked by peers and adults alike for his charismatic personality and sense of humor. For the past 3 years he has been the President of his high school’s Student Counsel and a member of the debate team.

• He has always been very ambitious and goal driven. He has said that he hopes one day to pursue a career in community organizing or social work because of his passion for helping those in need and creating a positive change in the world. He was responsible for advocating for vegetarian lunch options in the school cafeteria, as well as for an organizing various charity fundraisers and activities for the student body.

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Case Example “Barack” (cont.)• In the past two months, Barack’s teachers have observed a change in

his mood and behavior, as well as a noticeable drop in his academic performance. His recent progress report indicated that his grades have dropped from all A’s and B’s to mostly C’s and his number of days absent was the highest it has been all year. When his counselor asked him about this, Barack attributed the changes to feelings of increased pressure and stress that has interfered with his ability to focus on his studies. He cited concerns about leaving his foster family and living on his own. Recently, his primary focus has been on securing a full time job and purchasing a car. His foster parents are currently focused on moving to Florida after Barack transitions to independent living. They have not expressed any intention of staying in touch with Barack. They are not aware that this is increasing Barack’s anxiety about his future.

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Case Example “Barack” (cont.)

• Barack’s mother passed away when he was 3 years old. He was raised by his grandparents until his grandmother fell ill and was unable to care for him. He was brought into care and placed with the Johnsons at the age of 9. His grandparents have always maintained a consistent presence in his life, although they have been unable to care for him due to the fact that they live in an assisted living facility. Barack has no other known relatives. It is suspected that Barack’s anxiety about aging out of care is driven by his worry about what will happen when his grandparents pass and the loss of all of the family connections that he has ever known.

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Activity #1• Review story with your team• Complete the Trauma, Strengths, Life Domain Functioning,

Behavioral/Emotional and Transition to Adulthood Module• Summarize the needs.

• Try to avoid planning. Stick to assessing and communicating action.

Young Barack• 17 Year Old

• Transitioning to IL

• Losing family supports

• Many Useful Strengths!

• How can we incorporate needs and strengths into planning?

Life Domain Functioning

Behavioral/Emotional Needs

Trauma Experiences/Stress Symptoms

Identified Strengths

Caregiver Needs

Activity #2•What is the desired outcome? Define your goal. What will things look like when our work is complete?

• The goal should help illuminate

the treatment targets.

Activity #3•How will we get there? Define the actions steps. Define the intervention.

• Define the interventions.

• What will address the

need? How can we

use this strength?

Re-Assessment

•How is the re-assessment different from the initial?•Team members•Level of involvement•Time frame•Action Plan

Two Key Elements of the Re-assessment

• Identify and monitor progress

towards goal achievement

• Identify any changes that may have occurred since your last assessment

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Teaching Outcomes Management

• Use the Organized Re-Assessment Activity

• Model role play use of prior assessment/plan to drive re-assessment

• Review data reports to track progress over time on anticipated outcomes

Language

• It is getting easier for me to integrate the CANS into the way I regularly engage with youth and families

• I can easily find someone in my department or at my agency who can help answer my questions about the CANS

Effective teaming

• Work together with a youth or family to create CANS item ratings which everyone understands

• Explain to another professional or member of the youth’s support network why we are using the CANS

• Create a shared understanding with a youth or family of how we'll use the CANS

Consensus Building

• Help people who disagree about a CANS item's rating come to a working consensus

• Use the CANS ratings over time to identify places we are 'stuck' or need extra help

Collaborative Case Planning

• Use the CANS to develop service goals which are priorities for the youth and family

• Describe how a family’s service plan goals relate to ratings on specific CANS items

• Describe how providing specific resources and interventions will affect ratings on specific CANS items

Outcomes Referral Management

• Use the CANS ratings over time to identify a youth or family’s progress on their service plan

• Use the CANS ratings over time to celebrate successes with a youth or family

• Use the CANS to begin transition planning with a youth or family